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Accidents, failures, and other crises are usually followed by investigations, which find out what went wrong, and recommend changes to prevent a recurrence. The problem is – those recommendations are not always implemented, and the same thing happens again.

How could NASA lose Columbia having previously lost Challenger? Another example concerns the death of Peter Connelly in 2007. In 2000, Victoria Climbié was killed by her guardians in the same London borough. The inquiry into Victoria’s death noted failures among agencies responsible for monitoring vulnerable children: local authority, social services, NHS, police.  The inquiry chair, Lord Laming, found that child protection agencies had ignored his advice, revealing in 2008 his despair about failures to implement changes which were ‘little more than basic good practice’.

These are situations where change should be routine, but it’s not. One explanation for these problems concerns organisational learning difficulties.

There is no point in ‘learning lessons’, however, if these are not implemented. This is a change management problem.

To find out what goes wrong, we studied the death of a hospital patient. The story begins with Mrs Maylands’ admission to Magill Hospital (pseudonyms) in 1999, and takes us through her readmission for minor surgery in 2005, to her death later that year.

The story continues with the inquiry into her death, followed by three reviews of progress in implementing the inquiry’s recommendations. The final review was in 2010.  By that time, five years after the event, only 19 of the 46 recommendations were ‘completed’. The majority had either not been implemented, or had ‘issues’.

The research shows that post-incident change stumbles across three hurdles.

• Approach: The person-centred approach to accidents asks ‘who dunnit?’, and looks for individuals to blame. The systems approach asks ‘what organizational conditions allowed this to happen’, and looks for ways to remove the ‘error traps’ that make incidents appear to be due to individual failings. The evidence suggests that most serious incidents involve system failures. However, that does not stop investigators, management, and the media from hunting down and punishing the guilty.
• Causality: What caused Mrs Maylands death? The coroner put this down to a drugs interaction – a prescribing error. But maybe it was due to the fact that one of the two other drugs that would counter that interaction was out of stock? Or that Mrs Maylands’ deteriorating condition was not spotted over a holiday weekend? Or the confusion over which doctor was responsible for her care? Or the minor surgery that went wrong, requiring a repair, after which she remained in hospital and caught a Clostridium Difficile infection? Or the faulty walking frame that she was given, leading to fall, which required a hip replacement operation, which then led to her being prescribed the two drugs that finally proved fatal? There may have been one cause, but there were many becauses, and if those are not addressed, this can happen again.
• Process: Change Management 101 says, appoint a project lead, communicate to stakeholders to get buy-in, and address resistance. The textbook doesn’t say, ‘publish the changes and people will implement them’. But that seems to be the expectation. Post-incident change is like any other change; what’s in it for me, and what’s against my interests?

The answer is simple. Adopt a systems approach to understanding what happened. Avoid blaming individuals, and redesign the conditions in which they work. Look beyond the cause to the ‘becauses’, and deal with those, too. Design a process through which to manage the changes. This answer is not simple to apply. However, if you don’t, then ‘never again’ may become a hollow promise.